Resultados a largo plazo del tratamiento quirúrgico de las fístulas arteriovenosas durales espinales en un centro Argentino / Surgical treatment of spinal dural arteriovenous fistulas: Management and long-term results in a series of patients operated in an Argentinian center

Resumen Introducción: La fístula dural arteriovenosa espinal (FDAVE) es una enfermedad vascular frecuentemente subdiagnosticada. El tratamiento puede ser microqui rúrgico o endovascular. Métodos: Estudio retrospectivo de una serie de pa cientes con FDAVE tratados por microcirugía entre los años 2010 y 2021. Fueron evaluados parámetros como edad, sexo, cuadro clínico pre y postoperatorio medido con las escalas de Aminoff-Logue y Rankin modificada (mRs). Los estudios diagnósticos se utilizaron para de terminar nivel lesional y resultados quirúrgicos. Resultados: Se incluyeron doce pacientes (10 hombres y 2 mujeres) con un promedio de edad de 60 años. El tiempo de evolución del cuadro clínico al diagnóstico fue menor a 12 meses salvo un caso de 32 meses. Las FDAVE fueron localizadas, 8 a nivel dorsal, 3 a nivel lumbar y una a nivel sacro. La arteria de Adamkiewicz se identificó en 5 casos en L1, 2 en D12, 2 en D10, 2 en D9 y un caso en D7. De los 12 pacientes operados, 3 fueron embolizados previamente; dos permanecieron estables en su evolución y 10 mejoraron uno o más puntos del mRs. No hubo complicaciones en el postoperatorio. Todos mostraron mejoría del edema medular en reso nancia magnética y la angiografía digital, luego de los 6 meses, fue negativa. El seguimiento promedio fue de 40 meses con un rango de 6 a 122 meses y ningún paciente presentó recidiva de la FDAVE. Conclusión: El tratamiento quirúrgico de las FDAVE es un método muy eficaz, de baja morbilidad y menor tasa de recurrencia comparado con el tratamiento en dovascular.

Abstract Introduction: Spinal dural arteriovenous fistula (SDA VF) is a rare vascular disease, of unknown etiology, fre quently underdiagnosed. Treatment can be microsurgical or endovascular. Methods: Retrospective and monocentric analysis of 12 SDAVF patients treated by microsurgery between 2010 and 2021. Parameters including age, sex, pre and postoperative clinical condition were analyzed according to modified Aminoff-Logue and Rankin scales. Diagnos tic studies such as magnetic resonance imaging (MRI), magnetic resonance angiogram (MRA) and spinal digital subtraction angiography (DSA), were evaluated for lesion level, as were surgical results. Results: Twelve patients (10 men and 2 women), average age: 60 years, were operated. The interval from symptom onset to diagnosis was <12 months in all cases except one (32 months). SDAVF locations were thoracic in 8 cases, between T6 and T12, 3 at lumbar spine (L1- L2) and at S1 in one case, with no difference regarding side. The Adamkiewicz artery was identified in 5 cases at L1, 2 at D12, 2 at D10, 2 at D9 and 1 at D7 (7 left-sided and 5 right-sided). Three of the 12 patients operated had undergone prior embolization. Postoperative neu rological outcomes showed: 2 patients remained stable and 10 improved one or more points on the mRs; no postoperative complications were observed. Follow-up MRI images improved in all cases and spinal DSA was negative at 6 months. Average follow-up was 40 months (range 6 to 122) and no patient presented recurrence. Conclusion: Microsurgical treatment of SDAVF proved to be efficient, with low morbidity and lower recurrence rates compared to endovascular results.

Microcirugía de las fístulas durales arteriovenosas espinales, más un repaso de la anatomía vascular vertebromedular / Microsurgery of spinal dural arteriovenous fistulas, plus a review of the vertebromedullary vascular anatomy

Introducción: la fístula dural arteriovenosa espinal (FDAVE) es una enfermedad vascular rara, de etiología desconocida y frecuentemente subdiagnosticada. El tratamiento puede ser microquirúrgico o endovascular. Material y Método: Análisis retrospectivo de una serie de 8 pacientes consecutivos con FDAVE tratados por microcirugía entre 2010 y 2020. Fueron evaluados parámetros como edad, sexo, cuadro clínico pre y postoperatorio medido con las escalas de Aminoff-Logue y Rankin modificada. Los estudios diagnósticos con RMN (Resonancia Magnética Nuclear), ARM (Angio Resonancia Magnética) y ADM (Angiografía Digital Medular) se utilizaron para determinar nivel lesional y resultados quirúrgicos. Resultados: Fueron operados 8 pacientes (7 masculinos y 1 femenino) con un promedio de edad de 58 años. El tiempo de evolución del cuadro clínico al diagnóstico fue menor a 12 meses salvo un caso de 32 meses. Las FDAVE fueron localizadas en: 6 a nivel dorsal entre D6 y D12, una en L2 y la última en S1 (5 derechas y 3 izquierdas). La arteria de Adamkiewicz se identificó en: 4 casos en L1, 2 en D12, 1 en D10 y un caso en D7 (6 izquierdas y 2 derechas). De los 8 pacientes operados, 3 fueron embolizados previamente. La evolución postoperatoria del cuadro neurológico fue: 2 de 8 permanecieron estables y 6 de 8 mejoraron uno o más puntos en la escala de Rankin modificada; no hubo complicaciones en el postoperatorio. Todos los pacientes mejoraron las imágenes en RMN diferida y la ADM luego de los 6 meses fue negativa. El seguimiento promedio fue de 48 meses con un rango de 11 a 116 meses, ningún paciente presentó recidiva de la FDAVE. Conclusiones: El tratamiento quirúrgico de las FDAVE es un método muy eficaz, de baja morbilidad y menor tasa de recurrencia comparado con el tratamiento endovascular.

Introduction: Spinal dural arteriovenous fistula (SDAVF) is a rare vascular disease, of unknown etiology and frequently underdiagnosed. Treatment can be microsurgical or endovascular. Material and Method: Retrospective analysis of a series of 8 SDAVF patients treated by microsurgery between 2010 and 2020. Parameters including age, sex, pre and postoperative clinical condition were analyzed according to modified Aminoff-Logue and modified Rankin scales. Diagnostic studies such as MRI (Magnetic Resonance Imaging), MRA (Magnetic Resonance Angiogram) and spinal DSA (Digital Subtraction Angiography), were evaluated for lesion level, as were surgical results. Results: Eight patients (7 male and 1 female), average age of 58 years were operated. The interval from symptom onset to diagnosis was less than 12 months in all cases except one (32 months). SDAVF locations were thoracic in 6 cases between T6 and T12, at L2 in one and at S1 in one case (5 on the right and 3 on the left). The Adamkiewicz artery was identified in: 4 cases at L1, 2 at D12, 1 at D10 and in one case at D7 (6 left-sided and 2 right-sided). Three of the 8 patients operated had undergone prior embolization. Postoperative neurological outcomes showed: 2 patients remained stable and 6 had improved one or more points on the modified Rankin scale; no postoperative complications were observed. Follow-up MRI images improved in all cases and spinal DSA was negative at six months. Average follow-up was 48 months (range 11 to 116 months), no patient presented recurrence. Conclusions: Microsurgical treatment of SDAVF proved to be efficient, with low morbidity and lower recurrence rates compared to endovascular results.

Schwannomas vestibulares quísticos / Cystic vetibular schwannomas

Objetivo. Presentar nuestra experiencia en el tratamiento de los Schwannomas vestibulares quísticos comparándolos con lesiones sólidas. Material y método. Se evaluaron en forma retrospectiva los síntomas de presentación clínica, tasas de preservación facial, grado de resección quirúrgica, complicaciones postoperatorias y hallazgos histológicos de los Schwannomas quísticos pareados en base al tamaño tumoral con un grupo de lesiones sólidas. Resultados. Durante el período junio 1995 julio 2010, 27 pacientes con Schwannomas quísticos se operaron en nuestro Departamento. El diámetro promedio fue de 29,6 mm. Los síntomas de presentación clínica más frecuentes fueron la hipoacusia, inestabilidad en la marcha y parestesias faciales. Al año de cirugía, el 74% de los pacientes tenían función facial HB I-III sin diferencias significativas con el grupo de lesiones sólidas. La remoción completa fue 55,5% y 85% de los pacientes en las lesiones quísticas ysólidas respectivamente. Conclusión. Los Schwannomas quísticos deben ser evaluados en forma separada de las lesiones sólidas debido a que pueden crecer rápidamente, presentar mayor complejidad quirúrgica y desarrollar complicaciones postoperatorias con mayor frecuencia.

Objective. To present our experience treating this rare tumor variant.Material and Method. Retrospective evaluation of an institutional cystic vestibular schwannoma series, based on initial symptoms, rate of facial preservation, extent of surgical resection, postoperative complication rate and cystic lesion quantificationon histology in comparison to solid tumor type. Results. During the period June 1995-July 2010, 27 cysticschwannomas were operated on at the FLENI neurological Institute. Mean tumor diameter was 29,6mm. The most frequent presenting symptoms included hypoacusia, unsteadiness and facial paresthesias. One year after surgery, 74% of patients presented facial function HB I-III, showing no statistical difference in comparison to solid lesions. Complete surgical resectionwas possible in 55, 5% of the cystic and 85% of the solid tumor groups, respectively. Conclusion. Cystic vestibular schwannomas should be identified separately from vestibular schwannomas in general, particularlybecause they often undergo more rapid expansion, and may present greater surgical risk as well as higher rates ofpostoperative complications.

Diseminación meníngea atípica en meningiomas anaplásicos / Atypical meningeal dissemination in anaplastic meningioma

Objective. To present two cases of aplastic meningiomas refractory to surgical and radiotherapeutic tretement, with torpide evolution and clinical deterioration. Descpription. Case 1. 61, female. Left extraaxial temporo-occipital formation enhancing with gadolinium, tentorial implantation. Simpson II resection. PA: atypical metaplasic meningioma, EMA, VIM and PGR positive, Ki-67; 13%. Without parenchimal infiltration. Local 3D radiotherapy. Visual deterioration, walk disturbance. Relapse with compromise of rectus and transverse sinuses. Simpson II resection. In 12 months, progression of the disease along the convexity. Paliative treatement with hidroxiurea. Case 2: 69, female. Rt. Occipito-parietal meningioma 1995 subtotal resection in other center. Radiotherapy of remnant tumor. 2001 reoperated. Simpson II resection. PA: meningtheliomatous meningioma Ki-67: 5%. Dec. 2006 total resection of relapsing anaplastic meningioma. June 2007, extensive FPT dural dissemination. Medical treatement. Discussion. Anaplasic meningiomas present an exponential growing pattern that differenciates them from better grade lesions, possibly mediated by genetic factors (10q, 14q, 9p deletions). However, the only independent predictor seems to be the cellular kinetic index Ki-67. 5yr. 95% and 10yr. 79% survival rates are reported for anaplastic meningiomas with shorter relapse delays. Conclusion. High aggressive recurrent dissemination of anaplastic meningiomas is uncommon. Simpson´s I or II total resection is the initial tratement complemented as second line treatement by radiotherapy. Chemotherapy is of scant utility.

Meningiomas del surco olfatorio: tratamiento quirúrgico / Olfactory groove meningiomas: surgical treatment

Objective. To present our experience in the management of olfactory goove meningiomas analyzing their clinical presentation, radiological features, surgical outcomes and postoperative complications. Methods. A retrospective study was conducted by analyzing the charts of the patients including surgical records, imaging studies and histopatological records. Results. A total of 304 meningiomas were operated on betwiin 1994-2007 in our department. There were 16 patients with olfactory groove meningiomas including 9 women and 7 men. A men age of 52.8 yr (age range 21-72yr). The most frequent symptom was a higher function impairment (5pt). Olfactory simptons were infrequent in our series. The average maximum tumoral diameter was 5.8 cm. The approaches used were the subfrontal, bifrontal craniotomy with orbital osteotomy, pterional and frontolateral. CSF fistula was the most frequent complication. Perioperative mortality was recorded in two cases. No relation with surgery was demonstrated. The mean follow-up period was 78 months. Conclusion. The olfactory groove meningiomas reaches a big size due to delay in diagnosis. The best treatment is the surgical excision with a surgical approach wich provides quick access to the tumor with the lesser morbimortality possible.

Quistes dermoides y epidermoides intracraneales / Dermoid and epidermoid itracranial cysts

Objective. To present the clinical and radiologic features and surgical results in the management of dermal and epidermal cysts treated in our institution between 1997 and 2006. Material a method. Age, sex, way of presentation, location, radiologic features, surgical technique and compications of 15 epidermal and 1 dermal tumors diagnosed between may 1997 and October 2006, were retrospectively assessed. Results. Mean age: 43 yrs. Most frequent clinical manifestation: headache. Most tumors were at CPA. All resections were done with microsurgical technique. There were 3 cases of chemical meningitis that resolve without sequel. Discussion. Dermal and epidermal cysts are originated by inclusion of ectodermic material at the moment of occlusion of the neural tube. They represent the 0.3-1.5 of intracranial tumors beeng dermal 5-9 times less frequent. The most frequent location of epidermal cysts is at the CPA while dermal are more frequent in the midline. Clinical fatures depend on location. MRI is the gold standard for diagnosis, epecially the DWI sequence. CT is important for the detection of bone invasion. Treatement is so extensive as possible surgical resection, difficult, sometimes because of strong adhesions to eloquent structures. Conclusion. Dermal and epidermal cysts are high fat content lesions, that produce edherence to neural structures. Surgical excision is the election tratement.

Síndrome de área motora suplementaria postoperatoria: Reporte de un caso / Postoperative supplementary motor area syndrome: Report of one case

Objective: To analyze the anatomical and semiological features of the syndrome of the SMA through the presentation of a patient. Description: 55 female. Two yrs history of generalized convultions. Left frontomedial lesion biopsied outwards. PA: low grade astrocytoma. Medically trated until feb 2007. Sudden headache and right sided hemiparesis with crural predominance. Hoffmann and slight right hyper reflexia. MRI: expansion of primary lesion with intra lesional hemorrhage. Surgical resection. PA: mixed anaplastic glioma. The inmediate postoperative status was of a right CB plejia with severe apathy and abulia with right spatial hemineglect and hypofluent and anomic language, with preserved repetition and comprehension. Total recovery of paresis and language except when stressed. Discussion: The SMA is limited by cingulated cortex inferiorly, PMC posteriorly, and vertex surperiorly. The anterior border is not well defined. SMA activates before the PMC, during planification and iniciation of movement. Is connected with the PMC, spinal cord neurons, basal ganglia and contralateral SMA. By intraoperative stimulation it could be established the somatotopic organization of SMA, with the hindlimb posterior the forelimb intermediate and face anterior. Before the facial representation is the language area in the dominant hemisphere. Epileptogenic crisis originated in this area produce abduction and supination of the contralateral forelimb with deviation of the head to the same side. The syndrome of lesion of SMA includes: global akinesis, proximal predominance of motor deficit, with secuelar difficulty for the fine movements of hands an a quick recuperation (days to weeks). Conclusion: The syndrome of the supplementary motor area is well recognized after medial frontal lobe surgery. Its features include reduction of spontaneous movements in the contralateral limbs and speech deficit. The impairment of volitional movements is the main finding...

Angiomas cavernosos de tronco cerebral / Brain stem cavernous angiomas

Introduction: The incidence of intracranial aneurysm ranges from 0,5 to 0,6 por ciento and the diagnosis of incidental aneurysms has increased due to the development of non invasive neuroimaging techniques. Minimally invasive treatment modality in incidental cases. Methods: A series of 119 incidental aneurysms in 77 patients were treated by embolization with GDC coils. Results: One hundred and seven aneurysms were succesfully embolized with total or almost total occlusion rate of 86,8 por ciento. Thirteen procedural complications occurred causing definite morbidity in 5 patients and one death. None of the embolized aneurysms bled during the follow up. Conclusion: Embolization of incidental aneurysms is associated to a low morbidity and mortality rates

Neuronavegacion en cirugias intracraneales / Neuronavigation in intracranial surgeries

Objectives: to present our experience with Neuronavigation system in intracranial surgery. Material and Methods: The use of neuronavigation system was evaluated in 104 consecutive patients operated on during the period September 1999 - April 2003 (Range of age: 5 months - 75 years). Surgical procedures included the remotion of brain tumor, arteriovenous malformation, cavernous angiomas and epilepsy surgeries. The neuronavigation system is the Elekta Insight View Scope (Elekta Instrumental). Results: The additional time required for preoperative organization of the Neuronavigation system was 30 minutes. There were no differences during the registration process related to the surgical position (prone, supine and park-bench). The reference system planning of the surgical approach, to guide endoscopical procedures, perform smaller craniotomies, localize deep-seated subcortical lesions, identify the boundaries of low grade tumors and evaluate the extent of resection in epilepsy surgeries. Conclusion: Neuronavigation system improves the surgical approach of intracranial surgeries allowing to short the operating time, define the less invasive trajector, and identify the margins of low grade lesions

Condrosarcoma de base de cráneo y enfermedad de Ollier / Chondrosacoma of skull basis and Ollierïs disease

Los condrosarcomas intracraneales son lesiones infrecuentes que pueden presentarse en forma aislada o el contexto de las condromatosis múltiples, como la enfermedad de Ollier y el sindrome de Maffucci. Reportamos el caso clínico de una paciente joven con diagnóstico de enfermedad de Ollier y condrosarcoma de base de cráneo analizando los diagnósticos diferenciales y su tratamiento quirúrgico.